Overview
During our audit period, Somerville-Cambridge Elder Services (SCES) did not submit required annual prior authorizations (determinations of MassHealth members’ clinical eligibility to receive adult foster care, or AFC) for AFC it provided to MassHealth members. Specifically, for 45 of 287 MassHealth members who received AFC, SCES did not submit 48 (53%) of 90 required annual prior authorizations. As a result, MassHealth paid for AFC that it did not authorize.
Authoritative Guidance
According to Section 408.417(B) of Title 130 of the Code of Massachusetts Regulations, prior authorizations are required for AFC before the first date of service and annually thereafter.
Reasons for Issue
SCES officials told us MassHealth did not have a process for providers to submit annual prior authorizations, although MassHealth authorizations were required as of May 5, 2017. MassHealth officials told us the agency could not process annual prior authorizations online until April 16, 2019. They stated that this was because of a two-year delay with the new vendor that was responsible for implementing MassHealth’s Long-Term Services and Supports (LTSS) Provider Portal, an online tool for submitting prior authorizations to MassHealth for AFC.
Recommendation
SCES should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.
Auditee’s Response
As noted in the audit report, during the period May 5, 2017 through April 16, 2019, SCES was unable to submit Prior Authorizations on the LTSS Provider Portal, as MassHealth did not have a process for us to make such submissions. The Portal was implemented on April 16, 2019, and since that time SCES has been submitting prior authorizations as required in the regulations. We will continue to maintain compliance with the Adult Family Care regulations regarding Prior Authorizations.
MassHealth Response
The Executive Office of Health and Human Services (EOHHS, MassHealth’s oversight agency) and MassHealth responded,
EOHHS agrees with the [Office of the State Auditor] that SCES should submit annual prior authorizations. EOHHS plans to conduct an audit of SCES to determine compliance with the prior authorization requirement for MassHealth-covered AFC.
| Date published: | June 29, 2020 |
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